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AIDS CLINICAL ROUNDS
TUBERCULOSIS AND HIV SCREENING IN HEALTHCARE WORKERS AT MAPUTO CENTRAL HOSPITAL, MOZAMBIQUE
Francesca Torriani, MD Susannah Graves, MD
University of California, San Diego May 17, 2013
AIDS Clinical Rounds – AVRC - UC San Diego
Estimated number of
cases
Estimated number of
deaths
1.4 million Range: 1.0 – 1
8.7 million (range: 8.3 –9.0 million)
All forms of TB
HIV-associated TB
1.1 million (13%) 430,000 (31%)
Why is TB still important in 2013?
Women Children
2.9 million (range: 2.6–3.2 million)
0.5 million
25% of TB cases are in Africa Highest rates of cases & deaths relative to population
0.5 million
HIV prevalence and TB incidence in Africa
Source: UNAIDS and WHO Source: WHO
HIV prevalence: 11.5% in Mozambique
TB incidence
Question 1
What is the HIV prevalence in Mozambique? A. 1-4.99% B. 5-9% C. 10-20% D. >20%
Site: Maputo Central Hospital
1500 beds total Medicine Wards: 112+ beds >65% patients HIV+ Pulm TB:
25-30 cases/mo cases in HCW? MDR-TB in HCW 3 cases in 2010 1 case in 2012
Patients waiting waiting to be seen in the Emergency Room
TB Infection Control Measures
Administrative Measures Risk assessment Infection prevention and control plan Administrative support for the program implementation,
including quality assurance Environmental Controls
Separate room Negative pressure room Natural ventilation Filtration UV lights
Personal Protection N95 respirators
TB Infection Control Measures: Administrative Measures
Screen regularly for TB Respiratory hygiene/cough etiquette Educate/Training of patients and staff Triage/Isolate suspect clients Rule out TB without delay Better coordination between TB and HIV services When identified Decrease time patients are hospitalized Defer admission of patients Rapid drug susceptibility assays Involuntary detention if resistance HIV testing
TB Control at Maputo General Hospital
Infection control committee chartered Sept 2011 TB control program chartered in late 2011 National TB reference laboratory acquired capacity
for mycobacterial culture and DST in early 2012 Unknown prevalence, incidence of HIV and TB in HCW Recent study of HCW from Northern Mozambique:
43% HIV prevalence 9 new TB cases (2.1% of enrollees).
Casas et al. Tropical Med and International Health. Aug 18, 2011.
TB Control Team, MCH
Pilot Study Methods - 1
Population: Internal Medicine Department Study Period: 1 week in February 2012 Recruitment: Flyers and an assembly advocating screening Eligibility Criteria – working in MCH Medicine
Department Enrollment and consent for HIV testing Questionnaire: Contact/ID, demographic data, symptoms
and history of HIV and TB, contacts.
Pilot Study Methods – 2
HIV testing (2 rapid tests) and CD4 count (flow cytometry) Chest Xray – read by a radiologist and a pulmonologist Sputum sample for those with productive cough
AFB smear and mycobacterial culture
Further standard of care workup (LN biopsy, CT scan) Treatment referrals as appropriate for HIV and TB
Diagnostic Algorithm for TB
Questionnaire Chest Xray Sputum x2 ordered if productive cough Pulmonary TB suspect definition
Symptoms or radiographic evidence of pulmonary disease
TB Case Definitions – WHO Definite: culture positive or 2+ AFB sputum smears Smear Negative: 2 NEG smears, abnormal CXR, no response
to a course of broad-spectrum ABX (unless HIV infected)
Pilot Study Demographics
No. % Total 156 100.0% Sex Male 35 22.4% Female 121 77.6% Age (years) 16–29 39 25.0% 30–39 56 35.9% 40–49 34 21.8% 49–59 23 14.7% >60 4 2.6% Time working in Hospital <5 years 52 33.8% 5-9 years 34 22.1% 10-14 years 17 11.0% 15-19 years 6 3.9% >20 years 45 29.2%
HIV Screening Results
N = 148/156 (95%) HIV tested
Pilot Study: Active TB
TB in 1/156 (0.6%) of HCW Screened • Asymptomatic at screening • Xray: mediastinal adenopathy • Developed diffuse adenopathy • Diagnosed via LN aspiration • Hospitalized: TB lymphadenitis
TB Symptom Screen Results
Pilot Study Radiographic Findings
Abnormal Xray in12 HCW Lymphadenopathy Diffuse opacities Nodular opacities “Bronchiectasis” Cavitary lesion
2/12 had prior Hx of TB 42% were HIV+ 25% had symptoms
Abnormal Chest Xrays by HIV Status and Symptoms
Microbiologic Data
19 HCW reported productive cough
Only 9 sputum samples obtained: AFB smear – negative in all 9 Mycobacterial culture – 8 negative, 1 contaminated
TB diagnosis during screening
A single case of TB was diagnosed
Generalized lymphadenopathy No cough Initial CXR – mediastinal lymphadenopathy LN biopsy – positive AFB smear Clinical decompensation hospitalized, treated CT chest – miliary TB + adenopathy
CT findings
Cases Diagnosed after Initial Screening
Among participants 2 more participants re-presented to the screening clinic Both were symptomatic Found to have AFB smear positive pulmonary TB
Among HCW’s who were not enrolled in our study 3 HCWs presented to the occupational TB screening service Symptoms: productive cough Diagnosed with active pulmonary TB One of them was MDR-TB
Pilot Study Discussion
Strong points: Ease of recruitment HIV testing and CD4 counts Difficulties: Obtaining sputum samples Tracking and quality of sputum cultures Diagnostic work up of TB suspects Maintaining confidentiality
Pilot Study Discussion
Strategies for improvement: Concrete diagnostic algorithm & case definition Documentation of follow-up and treatment Supervised sputum collection Better communication with TB lab Secure storage space for Xrays and other records Defined office space and hours for follow-up
Question 2
Which clinical symptom is the best to screen for TB? 1. Fever 2. Loss of weight 3. Chronic cough 4. Night sweats 5. ≥2 symptoms
Reid et al Lancet ID 2009
Reid et al Lancet ID 2009
Sensitivity and Specificity of Cough as a Symptom of TB Assess for signs and symptoms suspicious for tuberculosis
The Importance of Early Diagnosis
Prevent new infections: Suspect TB when Weight loss >1.5 kg in last month Cough more than 2 weeks Night sweats more than 2 weeks Fever more than 2 weeks Other: anorexia, hemoptysis, pleuritic chest pain
A diagnosis of TB should fast track patients to ARVs <200 Initiate TB treatment and ARVs <50 Initiate TB treatment and ARVs immediately
Screen and identify TB suspects Assess for signs and symptoms suspicious for tuberculosis
Not all patients will spontaneously report cough! Therefore you should ask: Do you have a cough? If yes, then ask:
How long have you been coughing for? Ask for additional signs or symptoms compatible with TB
Do you cough up blood? Have you had night sweats? Have you had a fever?
Measure current temperature Have you lost weight? How much? Measure weight Ask about previous history of TB in the patient, family or work contacts
Impact of Administrative Measures
Alone prevent < 10% of future XDR TB Early discharge after 5 days avert 6% Admission deferral of 25% clients prevented 7% Rapid drug susceptibility assays prevented 3% Involuntary detention without separate facilities build up
lead to an INCREASE 3%
Basu et al, Lancet 2007;370:1500-7
Question 3
How many sputum samples are sufficient to exclude active contagious TB?
A. 1 B. 2 C. 3
Diagnose TB Promptly
Collect sputum samples (OUTSIDE!) Two sputum samples from every TB suspect (one on
the spot, the second one day after) Two sputum samples identify 95% of smear positive
cases!
Give instructions to patients on Purpose of the sputum collection How to cough up How to handle the container Instruct them to collect 2nd sputum outside
Nelson, JCM, 1998;36:467; Wilmer, Can J Infect Dis Med Microbiol , 2011;22:e1
TB Diagnosis
When the above symptoms exist – send patient for AFB examination of the sputum x 2
In this setting a positive AFB is sufficient to provide a diagnosis of TB If sputum AFB is positive = patient is contagious
Handful of patients who are sputum negative, if there is a high enough suspicion for TB, may consider empiric treating
Key Points to Prevent TB Transmission
Screen regularly Isolate suspect patients and educate about cough hygiene Provide HIV and TB diagnostic and treatment services Promote mask compliance (protects you and your patients) Ensure good natural ventilation
Alert clients ahead of time that windows will be open and encourage them to bring a jacket and/or blanket
Know your status
Current Progress
Occupational Health/TB Screening Office was created with defined office space and secure storage for CXR and other records
Needs assessment for TB infection control in Emergency Room was done F-A-S-T: FINDING TB cases ACTIVELY by cough
surveillance and rapid diagnosis, SEPARATION and exposure reduction until effective TREATMENT starts
TB infection control plans with support from the hospital director
Environmental controls
Natural and/or mechanical ventilation Open windows and
doors Fans to dilute/direct
the flow to outside Filtration UV irradiation Isolation facilities for
MDR or XDR patients Basu et al, Lancet 2007;370:1500-7
Hospital Central de Maputo, Mozambique, Sala de Urgencias
Next Steps
The Study (CFAR Grant): Tuberculosis screening in all HCW at MCH Active and latent TB High-risk latent TB (HIV, high-reactors) The Ultimate Goal: Incorporation of routine TB screening into
occupational health at MCH Comprehensive TB control program at MCH
Active TB in HCW 2013 Survey
Aim: To assess annual incidence of active tuberculosis in health workers at MCH.
A publicity campaign with posters and departmental trainings advocating early identification, triage, and treatment of TB suspects, cough etiquette and appropriate mask use.
Twelve months after the initial screen, physicians in the medicine department who treat TB were surveyed via phone to report cases of TB in health workers from MCH.
Active TB in HCW 2013 Survey Results
Twenty cases of active TB in HW were reported: 14 pulmonary 5 extrapulmonary 1 pulm and extra pulm
19 new cases and one re-treatment Three new cases (16%) were MDR-TB 13/20 (65%) AFB smear + 3/20 (15%) AFB smear - 4 did not provide samples HIV status
4 (20%) HIV+ 10 (50%) HIV – 6 unknown
Healthcare workers included medical students, orderlies, nurses, and physicians in at least 8 different departments
Discussion
Given the large number of cases and alarmingly high rate of MDR-TB among HW, MCH has moved to expand the TB office to address gaps identified in current screening and treatment practices.
Gaps include: No active case-finding Lack of sputum specimens for those patients without chronic cough Unknown HIV status in 30% of HCW diagnosed with TB
To address these, the TB office was allocated space and equipment for sputum induction.
Outside funding was secured to screen for active and latent TB and HIV in 500 HW with a plan for annual screening in the future.
Furthermore, to curb transmission, hospital allocated funding for phase 1 of a two-phase plan for an ultraviolet germicidal irradiation installation and triage-isolation protocol in Urgent Care.
TB infection control plan - Urgencias
Patients
Consult
Waiting
Add UV fixtures
Operate all ceiling fans
By Anna Levitt
Acknowledgements
Elizabete Nunes, MD, PhD Francesca Torriani, MD Philip Lederer, MD Sophia Viegas Koen Hulshof, MD Anna Levitt, PE Joaquim Aracua, MD Anilsa Daniel, MD Catarina David, MD Anila Hassane, MD
Thank you Questions and Suggestions?